Western HAN members are currently waiting—for national health care reform to take shape, for the impact of state budget cuts to become clear, and for confirmation that the CeltiCare Bridge program provider network is broad enough here to begin enrolling eligible legal immigrants on December 1.
A special team including Connector, MassHealth and CeltiCare staff is finding solutions for some Aliens With Special Status (AWSS) immigrants who haven’t been able to get their medical needs met through MassHealth Limited and or the Health Safety Net while they’re waiting to be enrolled in the Bridge program. But these issues must be raised by advocates on a case-by-case basis, and outreach workers are concerned about those who don’t have anyone working on their behalf.
Some pregnant women with AWSS status have had trouble accessing prenatal care. HAN members suggested that because they’re on the list of people waiting for CommCare Bridge enrollment, they’re not being bumped up to MassHealth Standard as they should be according to recent changes. Instead, they are remaining in MassHealth Limited’s emergency-only care. One HAN member has been reassured that coverage will be retroactive once the problem is fixed.
Commonwealth Care clients who try to re-enroll after paying overdue premiums are also hitting a snag. One HAN member reported having five cases in the past two months in which she had to call the Connector repeatedly in order to ensure that an overdue marker was removed from a client’s record so coverage could resume.
Outreach and enrollment workers are also concerned for their elder clients; Medicare premiums are rising and there will be cuts to Prescription Advantage. However, the change to a higher asset limit will give many more people access to the Part B premium savings program. Open enrollment for Medicare Part D is upon us (Nov. 15 – Dec. 31), and people dually eligible for Medicare and MassHealth may be reassigned. More information on these topics is available in the November SHINE Flash newsletter.
Some announcements pertinent to Western Mass:
Amy Whitcomb Slemmer, Executive Director, Health Care For All
The state budget deficit has been projected at $600 million; 9c cuts to date add up to $352 million. Though advocates were concerned that MassHealth’s adult dental benefits would be cut, they have not been; advocacy and phone calls are making a difference.
Two million in funding for the current fiscal year’s outreach and enrollment grants was transferred from the Health and Education Facilities Authority (HEFA) to the Commonwealth at 10:28 am on October 28. We are awaiting further news.
Thirty million dollars has been transferred from the General Fund to the Medical Security Program, which will keep the program afloat for the immediate future. However, cuts to premium assistance in the Prescription Advantage program will significantly affect many elders.
New CommCare Bridge members have experienced delays receiving the welcome packets they anticipated in the Eastern part of the state. November 23 is the target date by which we can expect all enrollees thus far to have received adequate information about their health plan.
Richard Lynch, President and CEO, CeltiCare Health Plan
Richard Lynch, President and CEO of CeltiCare, offered a brief history of the organization and insights into its planned operations in Massachusetts. He was joined by Brenda Rivera Saunders, CeltiCare’s Members Connections Representative, who is committed to making herself available to us in the Western part of the state. CeltiCare’s current focus in Massachusetts is to serve the Commonwealth Care population; though its parent company Centene has experience in Medicaid, they are not currently in the MassHealth market here.
The state selected CeltiCare’s bid to manage health care for the AWSS immigrants who were terminated from Commonwealth Care. They have developed the "Commonwealth Care Bridge" program for this purpose. They are rapidly expanding their provider network; the Eastern region has added about 40 new community health centers in the past month. They are now actively building a network in Central and Western Massachusetts to be ready to begin automatic enrollment of eligible people on December 1.
In order to offer a more affordable product, CeltiCare has deliberately not formed the most expansive possible network—but their priority is still to make sure members can get the care they need. For this reason, they are open to paying out-of-network providers to ensure certain members’ continuity of care. Rich cited recent instances in which CeltiCare has already paid for out-of-network services in order to meet immediate medical needs: four kidney transplants, a bone marrow transplant, and services for hemophiliacs. He also mentioned that CeltiCare is working with the state to identify pregnant members and get them transferred to the appropriate MassHealth program.
A recent article in the Boston Globe reported long wait times on CeltiCare’s customer service line, but 10 minutes was the longest wait time identified in their own internal audit.
A paraphrased summary of our discussion with Richard Lynch
Q: How should we help patients navigate the system in order to get out-of-network services covered?
A: Members and outreach workers can call us at 1-866-895-1786 and speak to CommCare Bridge’s prior authorization department. CeltiCare works with nurses and a physician to evaluate member needs on a case-by-case basis. Please use this number to report specific problems with as much detailed information as possible. We are also working with health systems outside of our network to proactively identify people who may need continued access to services once they enroll in the Bridge plan.
Q: A team at MassHealth and Commonwealth Care has been problem-solving cases of future Bridge members who have needed more care than the Health Safety Net and MassHealth Limited could provide during the transition period. Are you getting that list also, in order to be proactive for those members?
A: We don’t have that list. We have been conducting extensive outreach to members throughout the transition—some 20,000 phone calls to the first 11,000 enrollees——to educate them about and help them through the transition process. We will inquire about this list.
Q: Is there a Western Massachusetts member representative for CeltiCare?
A: Not yet.
Q: When you send out welcome packets to new members in West/Central, will it include a list of providers in network?
A: There is a trade-off in the timing: the earlier we send packets out, the less time we have to get information about providers together. Here’s how we have done it so far: the state sends a notice to members just before the start date, confirming their eligibility and encouraging them to call if they have questions. We follow up over the next few weeks by sending members a card, assigning them a PCP, giving them a welcome packet, and following up with a phone call. However, we are going to see if we can provide more of that information in advance of December 1 to the next round of automatic enrollees. We don’t have a list of providers yet, but they will have a number to call for that information.
Q: We understand that in order to keep costs down for the patient, you can’t have a contract with every doctor—but are you being sensitive to finding providers who are accessible to the most rural parts of Western and Central Massachusetts, as opposed to just the areas where people are concentrated?
A: We are being sensitive to that, and the Connector also has standards around access that we have to abide by.
Q: Can you say a little bit more about what providers are signed up? In Hampshire County, for example, there is one hospital. It’s not like there are other choices.
A: We are talking to many hospitals, and we’ve reached out to all the community health centers. Our experience in the last two months is that many sites sign on closer to the auto-enrollment date.
When we go live in December, if there is a member who needs to get a service at a community health center that we don't have a contract with, we're going to make every effort to see that the member gets the service. We’re trying to recognize that this is a transition, and that we have to flexible.
Q: I know there have been some changes in the co-pay structure, such as the $50 co-pay for brand-name drugs. Is there news on that?
A: The way the benefit is structured is that there is a $0 co-pay for generic medications, and a $50 co-pay for brand-name drugs. We recognize there are some brand-name drugs for which there are no generic substitutes in the same therapeutic class. We are working with the state to move some of those medications to Tier 1 so they will have a $0 co-pay. For example, there is no generic for insulin, so we have already waived the co-pay on that and on diabetic supplies.
These are the kinds of things we need to know about, so if you have thoughts about what would make this work better, I want to hear about it. Talk to us about it and give us a chance to respond and be accountable for what we’ve said we’d be accountable for.
Q: I know you’ve been asked about transportation before—out here it can be an even bigger challenge to get people to their care appointments.
A: The first thing we did in response to transportation was in regard to family planning services. There were concerns about women using Caritas sites having access to Plan B contraceptives. In response, we developed a system to cover transportation to an alternative site for emergency contraception.
We try to get creative with community health centers; we recognize that patients need access to specialty care and hospitals may not be nearby. In one case, CeltiCare actually bought a van and donated it—the site provides the driver and takes care of the shuttling logistics. We are looking at something like that as a possibility in rural areas—or it may be more of a taxi voucher system. We are trying to make this work within the budget we have.
Q: I heard recently that CeltiCare was on hold in Western Mass. because there is not yet a network. Is this true?
A: No—CeltiCare is not on hold here. The state does still need to look at our network and determine that it has appropriate access—and our expectation is that our network will be adequate. It’s possible that some confusion has resulted from a different decision we made that was recently reported: We had planned to launch a commercial product, which would require a separate contract and network; but in order to focus on meeting our commitments to the CommCare Bridge population we have delayed that project until January 1.
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